Body Contouring Consultation Form

Body Contouring Consultation Form
Client Information
Name*

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Email
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
How did you hear about us?

FacebookTwitterInstagramYouTubeTV CommercialOnline AdsPosters/BannersMagazinesNewspaperReferralOther
Medical Condition
What is your main goal?
Do you have a diet plan? If yes, please explain below:
Are you pregnant?*

YesNo
Are you breastfeeding?*

YesNo
Are you having regular exercise?

YesNo
Are you currently taking any medications? If yes, please list them below.*
Do you have any allergies? If yes, please list them below.*

Do you have any of the following?*

	Yes	No	Remarks
Liver disease
Cardiovascular condition (including high blood pressure)
Kidney disease
Skin disease
Thyroid glad problems
Gastrointestinal problems
Cancer
Immuno-compromised
Photosensitivity to sun
Epilepsy
Diabetes
Underoing hormonal therapy
HIV
Chronic medical conditions we should know about?
Allergies to latex, medications, herbal or natural supplements
Hearing aids, Pacemaker or Hormone Pellets (where ) or metal/medical devices implanted
History of Blood Clots
Implanted silicone?

Acknowledgment
Type a question

I understand that this procedure cannot guarantee 100% expected results.I understand that several treatments might be needed to achieve good results.I allow Transform 365 LLC to take photographs, videos and measurements of my before and after results as proof of the treatment.I allow Transform 365 LLC to use these photographs for case studies, advertising, marketing or educational purposes.I was educated that hyperpigmentation might happen temporarily as a result of treatment.I confirm that all information in this form is accurate and true to the best of my knowledge.
Your Signature

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Type a question

I understand that I am using a combination ow frequency ultrasound, vacuum radio frequency,fractional focused radio frequency and or wood therapy tools machine at my own risk.I understand that an evaluation is performed in order to determine if I am a good candidate for the Non-surgical Body Contouring Program.Should I sustain an injury while using the equipment, I agree to not hold Transform 365 LLC, the service provider responsible.I understand and acknowledge that payments for the above services are non-refundable. By my signature below, I certify that I have read and understand the contents of this Consent Form for Body Contouring.I further agree to provide at least a 24- hour notice of a cancellation or change in appointment time. There are no refunds if I am responding to treatment and decide to stop treatments. Should the service provider wish to use any photos of my progress other than for my personal file, I will sign a separate Photo Release form.
Your Signature

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Date Signed

MonthDayYear
Date
Liability Waiver
I understand that this activity might lead to personal injury therefore I release Transform 365 LLC to any liabilities like personal injury and damage. I also authorize Transform 365 llc to make medical decisions for me if needed and if unable to contact an emergency contact person.

YOUR RESPONSIBILITIES

1. Keep your appointments. We require a 24-hour advance notice to reschedule/cancel an appointment.

2. Follow your program as closely as possible. Report any deviations to the staff so that we can help you get back on track.

3. If you have any challenges whatsoever, please share them with us immediately. Remember, it is in both our interests for you to succeed in achieving your goals.

4. If you have any medical conditions, please share this program with your physician immediately. The service provider is not a medical facility and does not make medical decisions.
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Date Signed

MonthDayYear
Date
Should be Empty:

Body Contouring Consultation Form

Client Information

Medical Condition

Acknowledgment

Liability Waiver